Potential Mechanisms of COVID-19-related Intracranial Hemorrhage Due to Temporary Depletion of Vitamin K-dependent Coagulation Factors: An Illustrative Case.

Coronavirus disease 2019 (COVID-19)-related intracranial hemorrhage (ICH) is believed to be associated with at least one known risk factor for ICH, such as hypertension, hyperlipidemia, diabetes mellitus, severe pneumonia, or anticoagulation therapy. However, in this study, we report a case of ICH in a 14-year-old boy with mild COVID-19 infection without pneumonia who had no such risk factors. The only abnormal laboratory finding was temporary depletion of vitamin K-dependent coagulation factors. This case indicates that COVID-19 infection may cause simultaneous asymptomatic intracranial microhemorrhages and temporary depletion of vitamin K-dependent coagulation factors. This temporary depletion might transform the intracranial microhemorrhages into symptomatic ICH.

Impact of Additional Lipid-Lowering Therapy on New Ischemic Lesions of Diffusion-Weighted Imaging in Carotid Artery Stenting.

BACKGROUND: New ischemic lesions on diffusion-weighted imaging (DWI) are frequently found after carotid artery stenting (CAS) and sometimes cause neurologic deficit. We investigated the rate and the potential factor of new DWI lesions during the perioperative period of CAS in symptomatic patients at our institution. MATERIALS AND METHODS: Of 187 consecutive patients who underwent CAS (April 2013-August 2016), we investigated 60 symptomatic patients with artery-to-artery embolism from carotid plaque. During hospitalization for ischemic stroke, patients with more than 120 mg/dL of plasma low-density lipoprotein cholesterol (LDL-C) level or more than 100 mg/dL of LDL-C level in case of coronary artery disease were administered additional lipid-lowering therapy (ALL therapy), for example, the same statin as patients took or evolocumab for patients with the maximum tolerated dose of statin. All patients were implanted the same type of carotid stent by the same procedure as we predefined. We implemented data analysis to identify factors on new DWI lesions. RESULTS: New DWI lesions were observed in 17 patients (28%). Baseline plasma triglyceride level was found to be the factor of new DWI lesions. ALL therapy was administered to 26 patients, including 8 patients of evolocumab. The average period from the start of ALL therapy to CAS was 15 days. New DWI lesions occurred in 11.5% of patients with ALL therapy and 41.2% of patients without ALL therapy (P = .019). Multivariate logistic analysis showed that ALL therapy was an independent predictor of absence of new DWI lesions (P = .029). CONCLUSIONS: ALL therapy before CAS may reduce new DWI lesions.

Decreased serum sodium levels predict symptomatic vasospasm in patients with subarachnoid hemorrhage.

BACKGROUND: Symptomatic vasospasm is a major cause of morbidity and mortality in subarachnoid hemorrhage patients. Hyponatremia and dehydration due to natriuresis after subarachnoid hemorrhage are related to symptomatic vasospasm. Therefore, most institutions are currently targeting euvolemia and eunatremia in subarachnoid hemorrhage patients to avoid complications. We retrospectively investigated the predictors of symptomatic vasospasm with respect to water and sodium homeostasis, while maintaining euvolemia and eunatremia after subarachnoid hemorrhage. METHODS: We monitored changes in serum sodium levels, serum osmolarity, daily sodium intake, daily urine volume, and daily water balance for 14days after subarachnoid hemorrhage. Outcomes were assessed using the modified Rankin scale at 1month after subarachnoid hemorrhage. RESULTS: Among 97 patients, 27 (27.8%) had symptomatic vasospasm. Patients with symptomatic vasospasm were older than those without symptomatic vasospasm; the occurrence of symptomatic vasospasm affected outcomes. Serum sodium levels were sequentially significantly decreased, but within the normal range from 1day before the occurrence of symptomatic vasospasm. Serum osmolarity of the spasm group was lower than that of the non-spasm group. CONCLUSIONS: Symptomatic vasospasm occurs more often in older patients and affects outcomes. A decrease in serum sodium levels occurs a day before symptomatic vasospasm. This observation may help predict symptomatic vasospasm.

Detection of chronic obstructive pulmonary disease in community-based annual lung cancer screening: Chiba Chronic Obstructive Pulmonary Disease Lung Cancer Screening Study Group.

BACKGROUND AND OBJECTIVE: Detection of chronic obstructive pulmonary disease (COPD) is crucial in the management of COPD. The aim of this study was to establish the utility of a community-based lung cancer screening for detecting COPD. METHODS: In Japan, community-based lung cancer screening for residents who are 40 years or older using chest radiography is well established. A screening system in Chiba City, Japan, was used to detect COPD. The criteria to consider COPD at screening included age of 60 years or older, a smoking history and chronic respiratory symptoms. Participants fulfilling these criteria were referred for diagnostic evaluation consisting of pulmonary function testing (PFT) and chest computed tomography (CT). RESULTS: Of 89,100 Chiba City residents who underwent lung cancer screening, 72,653 residents were 60 years or older. Among them, 878 (1.0%) were identified with suspected COPD and referred for further evaluation. Of those identified, a total of 567 residents (64.6%, 567/878) underwent further evaluations, and 161 (28.4%) were reported to have COPD, with 38.5% of them requiring COPD treatment. To verify the diagnoses from the secondary evaluation centres, PFT and CT data were collected from 228 study participants, and 24.9% were diagnosed with COPD. CT findings classified according to the Goddard classification revealed that 20.1% of these participants had moderate to severe emphysema. CONCLUSIONS: COPD screening added to a community-based lung cancer screening programme may be effective in the detection of patients with COPD.

Lifestyle and osteoporosis in middle-aged and elderly women: Chiba bone survey.

Osteoporosis causes an enormous health and economic impact in Japan. We investigated the relation between lifestyle and bone fracture in middle-aged and elderly women. This was a population-based, multicenter, cross-sectional survey for postmenopausal osteoporosis in Chiba City, Japan (Chiba bone survey). This survey included 64,809 Japanese women aged > 40 years. All participants underwent anthropometric measurements including bone mineral density (BMD) and completed a structured, nurse-assisted, self-administered questionnaire also including patient lifestyle. Bone fracture during the recent 5 years was observed in 5.3%, and the fracture group had significantly higher age, BMI, and prevalence of delivery, family histories of kyphosis and hip fracture, diabetes mellitus (DM), dyslipidemia, kidney disease, exercise, fall, and osteoporosis, and had significantly lower BMD and proportion of menstruating participants. Logistic regression analysis revealed that bone fracture was closely associated with not only low bone mass but also age, fall, family histories of kyphosis and hip fracture, DM, kidney disease, menopause, and lifestyle factors of dieting, exercise, and alcohol. Women's health care focusing on lifestyle-related fracture risks such as dieting, exercise, and alcohol appears necessary to prevent bone fracture in postmenopausal osteoporosis.

Significance of blood aspiration in carotid artery stenting with Angioguard XP.

BACKGROUND AND PURPOSE: In some patients, angiographic flow impairment is observed during carotid artery stenting (CAS) using Angioguard XP (AGXP), resulting in neurological symptoms. CAS was thus modified to improve clinical outcome. METHODS: Ninety-seven patients were treated with CAS using AGXP from January 2008 to October 2009. In period I (January-December 2008; n = 53), blood aspirations were performed only in no-flow cases. In period II (January-October 2009; n = 44), blood aspirations were performed in no-flow and slow-flow cases. Clinical outcome, detection of microembolic lesions on diffusion-weighted imaging (DWI) and flow impairment during CAS were examined between these two periods before and after modifying the CAS procedure. RESULTS: Periprocedural transient ischemic attacks occurred in 10 patients (18.9%) and one patient (2.27%) in periods I and II, respectively (P = .018). Minor and major strokes were observed in two patients in each period (P = .849). New ipsilateral DWI lesions were detected in 25 patients (47.2%) and 11 patients (25.0%) in periods I and II, respectively (P = .024). Among 18 slow-flow cases, new DWI lesions were detected in one patient (9.09%) and five patients (71.4%) with (n = 11) and without (n = 7) blood aspirations, respectively (P = .013). Neurological symptoms were observed only in three of seven patients (42.9%) without aspirations, compared to one of 11 patients (9.1%) with aspirations (P = .043). CONCLUSION: Postoperative symptomatic stroke and new DWI lesions are significantly associated with blood flow impairment during CAS using AGXP. When flow impairment occurs, blood aspiration should be performed.

[Three dimensional MRI].

Three-dimensional(3D) MRI is discussed in the present and future clinical application. The newly reconstructed 3D MRI have been widely utilized as a routine examination, and 3D MRA have been substituted for cerebral angiograms in some diseases. The parallel image with multiple phased-array coils can improve time resolution and reduce MRI artifacts. Fusion of 3D anatomical MRI with CT, various functional MRI, SPECT, and PET results in precise diagnosis and improves the accuracy in navigational neurosurgery and stereotactic radiosurgery. High-field 3-tesla MRI can be clinically used, but its role on 3D MRI is not clear. As the data of 3D MRI and multi detector-row CT increases, it becomes the major problem how to restore and protect these data.